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The 2020 Public Services Trust Blog

Tuesday, October 19, 2010

Two missing links – accountability and information

By Charlotte Alldritt

Until this morning I had thought I’d understood the general gist of the Government’s White Paper, ‘Liberating the NHS’.  Even if, as Sir David Nicholson admitted, the Department is still “working on the detail” I thought I had a fairly firm idea of the direction of travel. 

But now – after four of the most senior managers of the NHS tried to explain it to the Health Select Committee inquiry on commissioning – I’m more confused than ever.  While the devil will indeed be in the detail, it is not clear how the whole system will align the incentives and levers of finance, clinical expertise and commissioning for quality care.  Add the need for £20 billion in productivity savings and a 30% cut in management costs, and it’s a significant mountain to climb.

A first step will be in making clear the relationships between the Department, local authorities, GP consortia, the NHS National Commissioning Board, primary care inside and out of the remit of GP commissioners, social care, Health and Wellbeing Boards, individual patients, GPs disengaged or disinterested with the new system architecture, and the whole range of other stakeholders.  Without clarity on these relationships, as Rosie Cooper, Labour MP for West Lancashire asked repeatedly “Where is the accountability”?

Accountability is one of my two prime concerns for the new system of commissioning for healthcare.  How will providers be held to account for the quality of their outcomes for individual patients in the new system?  How will commissioners be held to account for the outcomes they achieve for their communities?  To what extent are local authorities to take the rap?   Where will discussions on competing ideas of ‘appropriate’ resource allocation take place? 

We know that the NHS National Commissioning Board will have ultimate authority.  But, as each of the four witnesses this morning (Sir David Nicholson, Dame Barbara Hakin, Dr. David Colin-Thome, and Ben Dyson) intimated, the local dynamics of the system will be key to delivering efficient and effective healthcare.  Appropriate accountability structures and incentives need to be in place to engage both clinicians and patients to achieve this.

The second of my prime concerns underpins the first; information and data quality.  For providers, commissioners and individual GPs to be held to account there needs to be a body of credible information on comparative outcomes, inputs and transaction costs.  ‘How much would the new Commissioning management system cost per head?’ asked Chris Skidmore, Conservative MP for Kingswood.  The Department does not know yet, but is determined to see it “significantly below 5%” of total costs.  Who will be monitoring those costs and outcome measurements?  David Nicholson says that the NHS Information Centre will – for the first time – be a hub collection point for Commissioning Boards to submit their standardized data.

However, it is not yet clear the extent to which the Information Centre will prescribe data standards or data requirements (e.g. and especially in primary care where it is almost entirely lacking).  As Dame Hakin and Dr Colin-Thome suggested, peer-based scrutiny and competition on outcomes can be a powerful lever for improving quality amongst clinicians.  But will this data be collected and made available for comparison?  Furthermore, in the new age of transparent government, will this data be openly available to the public?

The 2020 PST Information and Technology Group have submitted a formal response to the Health Select Committee on the role of information for commissioning.  We believe that that the White Paper does indeed hinge upon the ‘information revolution’ that the Secretary of State speaks of. 

The absence of accurate data on performance, spending and costs leaves commissioners and the public blind when crucial decisions have to be made about investment in, or closure of, services.   When the DH refers to high levels of patient satisfaction with their health professionals, to what extent do patients know how their GP compares with others?  Since patients and the public cannot get the answers to simple questions like, ‘How good or bad is my local GP?’ or ‘Which local provider organisations provide the best care?’ they can’t make informed choices about where to get care.  And they can’t make an informed contribution to local health discussions such as the merger or closure of services. 

We therefore recommend, for example:

  1. Standardised national data sets need to be developed urgently for episodes in primary care and community services, similar to the routine data set on episodes of hospital activity.  These should be done incrementally so that that striving for ‘perfect’ does not extend the existing delay of many years.
  2. It should become a legal duty of all providers who are funded by the NHS – including individual clinicians – to collect standardised, high quality data on their individual patient activity and outcomes to meet the national standards
  3. Commissioners should have the power to require addition local data access and suspend providers’ NHS funding or referral of patients for failure to comply.

 To be a truly devolved system as the Government envisages for the NHS, requires publicly available, high quality data across the full range of health services.  Only then will we be able to build a system which engages clinicians and citizens to work together, and so delivers quality care for patients at lower cost.


The 2020 Information and Technology Group submission has been lodged with the Health Select Committee, which will report later in the autumn.  For all enquiries on our recommendations and other work, please contact Charlotte Alldritt ( 

Tuesday, April 13, 2010

A vision for 2020 information and technology: Part 1 – Education

By Charlotte Alldritt

The year is 2020.  Over the past decade, simple online technologies have transformed the way we access data and information, hold public services to account and engage with government.  Transparency is the watchword of the day.  The ultimate prize? Renewed political legitimacy and public services finally fit for purpose.  In the first of this series on the part technology and information have to play, I explore the potential for education. 

Susan is a mother of twins, living in London. Her children, James and Marsha, will be starting primary school next year. Each child has different learning and care requirements, with Marsha requiring extra support as she has special educational needs (SEN).

Online data to inform choice

Accessing the local authority webpage, Susan is directed to a GIS system and carries out a search for local primary schools based on her postcode. She personalises the search to showcase primaries with special needs facilities and tutorials. Susan is then able to access up-to-date information about every local school, including parent reviews on the facilities, teaching quality, ethos and atmosphere. Using an open database (with an accessible user interface linked to the local authority website), Susan can also compare data through a single comparative website – from Ofsted, the NHS, local authorities and other integrated service providers – to check for quality.  This would be the alpha version of Tim Berners-Lee’s  Digital Public has some other great examples – see pictured below.)


Power to verify personal data and information

Once Susan has applied online for her children’s primary school places, she is able to access the data held by the local authority about her and her children before it is transferred to their new schools. Using a Unique Identification Number and a password for each child, she will be able to make changes to data and information held on her children. For privacy purposes, only trained and security-cleared professionals will be able to crosscheck this information.  With Susan’s consent they may also refer to her family’s GP records (also accessible to Susan online and possibly via a third party – e.g. Microsoft’s HealthVault) if needed.

Cost-effective public services responsive to citizens’ needs

While none of the technology Susan is using is very new, Susan is now able to access a wealth of information that helps her to choose the best for her and her family.  In the wake of spending cuts after the 2009 recession, taxpayers could no longer afford to fund poor quality public services.  Armed with data and information, service users and professionals can assess whether they getting or delivering quality public services.  Susan can share this information with fellow parents online, talk to her peers, local leaders, MPs and officials via formal and informal feedback sites (similar to, for example, Kings Cross Local Environment or  She knows that her voice can make a difference.  Government and providers know they have to respond. 

Technology is integral, not an add-on

By now the internet is not a technology, but a way of being – it is part of the fabric of our lives; we communicate, socialise, create culture, buy/sell, read, watch, write online.  And it’s on our terms, at our convenience – any time of the day or night.  ‘Self-service’ online public services seemed like science fiction to some in the first decade of the millennium.  By 2020, the pace of technological change (and with it, the vast majority of public attitudes and behaviours) has forced governments and providers to catch up and open up.  Not only has this allowed for more accessible, personalised public services.  It is renewing a sense of active citizenship and political legitimacy – the decline of which was reaching crisis point only ten years earlier.


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